Punisher

I came across my old backpack and decided to move all of the first aid supplies I kept in a box in my trunk into it. I thought some of you all might like to see some pictures. More to come since that doesn't even include any pictures of the largest compartment

It looks parasitic......I am not certain what exactly to call it beyond that.......so Doc, what's up?

Yeah, yeah.....sure.....excuses, excuses....

Man, Doc, you're taking longer to get our CT than any radiology department I've ever seen.....

Rule #1 of EKG's: you can't assess for anything but rate and rhythm from a single lead. I can neither rule in nor rule out the possibility of cardiac origin for the problems described. *This is me covering my ass*

Sinus rhythm. No significant change between the strips.......why do you ask?

Upload the pictures to a site like www.photobucket.com and then copy the link the site gives you with the brackets then just paste it on here........

If she's got hemianopsia, my brain is going pituitary adenoma (I don't know why, but it sticks in my head) or a met or some other space occupying mass in that area.... Head CT If nothing on the CT, angiography of the vertebrals BMP (just to check everything) ABG (I'm an RT, we order these on everyone j/k) CBC (r/o infectious process) ESR (r/o inflammatory processes) PT/PTT/INR (rule out clotting disorders) Biopsy of the lump on the back of her head ( yes, go wake up the path residents) j/k

Intimal tear of the vertebral artery secondary to hyperextension injury causing impaired posterior cranial circulation? The loss of vision on one side and lack of other neurological symptoms (other than the trembling of the hands) would seem indicate something involving the cerebellum or occipital lobes.....that's just my guess...... The other consideration would be something along the lines of some form of intracranial infectious process- given the "cyst". What is the patient's temp? And why would the doc prescribe milrinone (Primacor)? Am I missing something in regards to some new off label use?

I won't begin to compare myself to Dr. Bledsoe, but I will say this that he is the type of doc I would like to be one day(meaning his character and his involvement with improving the system).

Not only is he an excellent researcher, who has done a lot for EMS and an outstanding doctor who has never forgotten that he started out as one of us.....he's also an outstanding person. If you have any doubts about this, please read on: http://www.jems.com/Columnists/bledsoe/articles/106702/ Standing in the Doorway of Eternity As you get caught up in emergency medicine, it’s easy to forget that the people you care for and transport are human beings. We begin to think of them as “cases” or “runs” or some similar term. But they’re mothers, fathers, parents, children, grandparents and more. One of the greatest things about EMS is the diversity of humanity we encounter. The best and most professional EMTs I’ve met do the job because they love people. But once you lose track of this concept, the whole practice of EMS becomes mundane. So take time to listen to your patients. Sometimes, you’ll learn that they were a part of history or have experienced significant events. I’ve had a conversation with a Jewish woman who was the only one in her family who escaped the Holocaust, a Japanese man who was interred during World War II despite the fact he was an American citizen, a former prisoner of war who was held for six years in a North Vietnamese prison, and many more. If you’re in medicine long enough, you’ll encounter patients who’ll become indelibly etched in your memory. And, on certain occasions, the memories of these patients will come to the forefront of your mind. This happened to me recently. While running some errands in an older part of a town near where I live, my mind began to wander, and I thought about a patient named Etta Mae Jones. I met Mrs. Jones one evening in 1995. I was working the night shift in the ED, and things were pretty slow. The nurses were passing time by cleaning out a refrigerator, moving some furniture and dusting. I was working on some page proofs I had carried with me to work. At about 11 p.m., the EMS radio crackled and a monotone voice revealed that they were en route with an elderly nursing home patient who had a fever. The brief report was not uncommon; the nursing home was one block from the hospital, and anything more detailed would have been useless. The crew rolled through the ambulance doors. They had obviously been asleep before the call. They took the patient to the assigned room, and I could hear them kindly and patiently asking her to scoot to the hospital bed. They walked past, pushing the stretcher, and dropped off the nursing home records as they walked out the door. As they disappeared, I heard them say that they hoped they wouldn’t be seeing us again that night. The nurses assessed Mrs. Jones and got her ready for me. I took a brief look at the chart and noted that she was 102 years old. I thought I knew most of the centenarians in our community, but I had never met her. We had only three patients in the ED at that time; one was 91 years old, the other was 95, and then there was Mrs. Jones. One of the nurses quickly calculated the average age of our patients as 96 years. They do silly things like that sometimes. So I grabbed the chart and went to see Mrs. Jones. She was an elderly black lady covered with two blankets. She appeared ill. Her eyes were shut and her face was wrinkled from years in the sun and the effects of age. Her hands and fingers showed that her life had been one of hardship and toil. I was unsure about her mental status. I walked up to her bed and quietly said, “Mrs. Jones.” Her eyes opened, and she focused on me. She said, “Is you my doctor?” I said, “Yes, ma’am, I’m Dr. Bledsoe — the emergency doctor. Dr. Wilkins asked me to take a look at you this evening.” She thought for a moment and said, “That’s fine. I hope I didn’t get you out of bed.” I answered, “No, ma’am, I’m up all night.” I quickly assessed her mental status. She told me her name was Etta Mae Jones and that she was from Nash, Texas, but now lived at the Pleasant Acres Nursing Home. She was 102 years old and was born in Vicksburg, Miss., in 1893 “on a beautiful Sunday morning.” I could tell that she was as sharp as a tack — quite unlike the other two patients in the ED. I learned that she had started running a fever several days before and Dr. Wilkins had started her on oral antibiotics — but she had not improved. She said, “I’ve got the rigors, and they just won’t quit.” I took her history and listened to her chest. The whole right lung field sounded horrible with rhonchi and wheezes. I ordered admission labs, a chest X-ray and asked respiratory therapy to come and obtain a sputum sample for the lab. I told Ms. Jones that she would need to be admitted to the hospital because she most likely had pneumonia. She looked me in the eye and said, “Doctor, is that necessary? I have been on this earth 102 years, and I think this might be my time to pass over.” I said, “Don’t say that. You’ll probably outlive me.” She laughed a weak laugh and said, “You don’t understand. I buried my husband over 50 years ago. He was a cook in the United States Navy and died when them Japanese sailors sunk his ship. I’ve buried all of my children and half of my grandchildren.” I asked, “How many grandchildren do you have?” She managed a weak laugh and threw her head back and said, “Lawdy, I don’t know. I kinda’ lost count somewhere along the way. I got a lotta’ grandchildren, great-grandchildren and even some great-great grandchildren — but I don’t knows how many.” She motioned me closer and whispered, “I don’t know what to think of these young uns’ today. They shoot each other, never get married, have babies when they is still kids. They don’t care about nuthin‘ and nobody cares about them.” I shook my head in agreement. Figuring she wanted to talk I asked, “So you never remarried after your husband died in World War II?” She said, “Oh gosh, no, doctor. When I married, I married for life. My husband may be dead —but we is still married.” I said, “I guess you have seen a lot in your day.” She said, “Well, I have seen some — some good, some not so good.” I learned that she was the granddaughter of two slaves given their freedom by President Lincoln in 1863. They fled Mississippi for Texas to avoid persecution. She told me about the Great Depression. She said, “Oh Lawdy, them days were tough — not just for us colored people — but for the white folks as well.” She told me that her father never wanted her to go to school because he needed her help on the farm. She had 11 or 12 kids — she wasn’t quite sure — but three died in their first few years. Being an inquisitive doctor, I asked her what killed them. She said, “I don’t know. The Lawd just called them home early. I call them my angels.” She remembered discrimination and the Ku Klux Klan. She said, “I always went to the bathroom at home before I went anywhere because I was not going to go into the colored bathrooms.” She spent more than 30 years “working for a nice white lady” doing housework. But her employer died, and she was too old to “hunt for another job.” She also told me that she had never been in the hospital until 1955 and that was to have her appendix out. She said that her surgery was at this hospital. I decided she needed to rest, and I needed to get back to work. I ordered her old chart from medical records and flipped through it. She was in amazingly good health — mainly outpatient tests and a hospitalization for a kidney infection. I noticed her chart said “Volume 2.” Out of curiosity I asked the clerk to check with medical records and see if there was a “Volume 1.” Within a few minutes the medical records clerk arrived with Volume 1. It was a testament to the history of medicine in the South. The doctors’ and nurses’ notes were made by ink pen in sometimes exquisite cursive handwriting. The doctors ordered drugs in drams and grains. I noticed that it was frequently noted that Mrs. Jones was moved to and from the “annex.” I asked one of the older nurses (who had worked at the hospital for 30 years) about the annex. She said, “Well, that was gone when I got here, but the annex is where they kept the colored patients. They would roll them across the street for surgeries and X-rays, but the rest of the time they stayed there in an open ward in the annex. It had heat but no air-conditioning.” She said that “colored” nurses worked in the annex and occasionally a white nurse would have to work over there (for which she got time-and-a-half in pay). I asked, “What happened to the annex?” She said, “Oh, they tore it down years ago to build the doctors’ building.” The admission lab results came back. Mrs. Jones was quite sick. Her whole right lung field was consolidated. We increased her oxygen. I spoke to Dr. Wilkins and wrote the admission orders. I went back to the room. Mrs. Jones was again asleep. I touched her, and her eyes opened. I said, “It is just as I thought. You have pneumonia, and we need to put you in the hospital so we can give you some potent antibiotics.” She said, “Don’t go to that trouble. The Lawd has told me that he is ready for me to come home — and I don’t want to keep the Lawd waiting.” I knew she didn’t have a Do Not Resuscitate form on the chart. I looked her in the eyes and said, “You’re sick, and I need to ask you a few difficult questions. If you were to quit breathing or if your heart were to stop, would you want us to start CPR and put a breathing tube in for you to breathe?” She said, “Oh Lawdy, no! That may be a hard question for you, but it ain’t a hard question for me. I have lived a good life. I have outlived most of my family. The Lawd is callin’ me home, and I am ready to go. Doctor, I’m just tired ... oh so tired ... I’m just tired.” I looked at her and said, “Sure, I understand. We can’t send you back to the nursing home. You’re too sick. But we will make you comfortable here. Do you have any family here?” She thought and said, “The granddaughter who takes care of me moved to Georgia. It’s just me, although I have a few kinfolks here and there.” I noted in the progress notes her desire not to be resuscitated and wrote the DNR order. Before long, the staff from the floor came to get her. As she rolled past me, they stopped, and Mrs. Jones said, “Thank you, Doctor, for waitin’ on me. I’m sorry to have troubled you.” I said, “It was no trouble. That’s my job. I wish we had more time to talk. I hope you get to feeling better.” She nodded her head and gave me a knowing look as they pushed her through the doors. Three days later, I saw her obituary in the paper. Her funeral was evidently one of the largest in town in the past several years. In addition to more than 100 direct descendents, she had numerous friends and fellow church goers. The final sentence of the obituary said, “Etta Mae and Willie Ralston are now together for eternity.” I smiled and thought, “That is as it should be. After all, they are married.” Dr. Bryan E. Bledsoe, DO, FACEP, is an emergency physician in Texas.

I used to be a flight respiratory therapist for the Air Force, but I only have two of the patches from the team I was on and I'm not parting with either of them.

Thanks for your well wishes. As for the golf, sounds like a plan.

I apologize for the error in regards to your age. I'll be a paramedic next year. Within a few years after that I will be an emergency physician. Perhaps after that you and I can resume this debate OK?

Personally I believe the medical director would probably be the primary person to pay for it, but the expectation probably exists that someone versed in ACLS and emergency care in general (i.e. a paramedic) would know better than to do it. It's one of those issues that would probably boil down to how well the plaintiff's lawyer argued his case to the jury. I'm going to ask a friend of mine who is a lawyer to comment on this......I'll let you know what his response is.

I think administering a medication that is proven to have negative consequences in the situation your giving it more than fulfills that criteria. Or were you to busy measuring yourself with a micrometer to pick up on what Scaramedic stated. Obviously you've spent your 40 some years so well...here you are picking a fight with someone half your age and doing a right piss poor job of it I must say. It's just so clear to us all that you are further proof of the adage that relying upon experience alone simply results in you making the same mistakes over and over again with an ever increasing level of confidence. I'm not threatening you with anything....I don't have to. Last time I checked, a respiratory therapist and echocardiographer has a lot more education than some smartass firefighter who obviously only maintains his paramedic credential so he can get paid even more for parking his butt on some recliner somewhere. It's quite apparent you are not in EMS for your patient's best interest or you would not be quite so obstinant towards those with more education and experience.

No, I said it hasn't been used for that purpose in over a decade and I haven't seen described in any of the back editions of the ACLS texts (which I own) since the early 1990's. As I said, you can abandon your cause. It isn't going to get you anywhere. :roll: BTW, yes I was a first responder at while still in high school.

Very good! If they do drop over, they are far more likely to be in VF than any other rhythm. Obviously you weren't too busy excavating the inside of your ear canal with your index finger during that little bit of the ACLS class! Now if you would please be so kind as to stop wearing your own rectum as a turban and pay attention to what I have actually posted you will find that I have stated exactly that. While this may be the US, and protocols do vary, it is precisely this lack of understanding of the medical literature as you demonstrated through discussing the use of CaCl[sub:1d19d40e3d]2[/sub:1d19d40e3d] in cardiac arrest- while you have a grasp on the basic physiology, you actually seem to miss the point that there was enough evidence against it's use for the AHA to pull it from the ACLS guidelines in the late 80's or early 90's. Now you might feel secure in going to court with the argument "But my protocols said to do X" but I assure you that when the plaintiff's attorney tears into you, he will not only plop a copy of your protocols down in front of you, but also probably (if he knows what he is doing) hand your your hind end on a platter by presenting every bit of research on the use of calcium in asystole and PEA, not much of which is very supportive of the person sitting on the defendant's side of the aisle. Maybe instead of blindly following what your medical director tells you, maybe you should try taking an active role in protocol development. But as you said, this is the US, you all can do whatever you see fit. Have fun...let me know how it turns out. :roll: By the way, thank you for your support Ace. That's one of my favorite scenes, from one of my favorite movies. Vinnie Jones (the guy who played Bullet Tooth Tony) was the person I tried to be when I played football:

Did I disagree with any of this (although I disagree with the recommendation of calcium since it has not been standard practice for over a decade (if not longer) except in calcium channel blocker OD or hyperkalemia), no......I disagreed with defibrillating tachycardia- not as in AVNRT, but more along the lines of sinus tach. That is my dissenting point, not with giving fluid (remember that I advocated fluid resuscitation), sympathomimetics (I stood behind the use of epinephrine), etc. You need to drop the attitude. You will not win any argument against me on this matter or any other medical matter. Ace, I am overstating my position here?

WTF? Over. I agree....Troll.

?????? :?

Changing the title doesn't change the disorder...uh, I mean certification.

Meaning that say the person abruptly grabbed their chest and collapsed, and is found in a narrow complex tachycardic rhythm, then chances are good that it's cardiac in origin, as opposed to someone who was complaining of tearing abdominal pain or as a result of a trauma then arrests. If there is a high likelihood that the heart isn't to blame, cardioversion/defib is not going to do anything for the arrest, except maybe seal the patient's fate. That is what I mean. Are we clear now?

Want to write it up Rid? I'd be happy to help. PM me if you're interested.

I think arrogance plays a major role in many of those missed tubes to be quite honest.